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w j APPLICATION FOR PERMIT S�JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIONS 1601 E. HAZELTON AVE. , PHONE (209)468--3420 / J P o BOX 2009, STOCKTON, CA 95201 /1 n� RRRMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �7 f✓ L�� S City Lot Size/Acreage 3-05.4 � y�/u- O Owner's Name _ Address Phon lrJsi�S /�l�lpCO B�i/� $/p Contractor /7 f7/1'7 Address 2L 6_53ucense No. ZZ Phone 372-S2�TZ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ UP�O�THER 'r Monitoring Well [3DISTANCE TO NEAREST: SEPTIC TANK n' SEWER LINES 75 I- DISPOSAL FLO. •PROP. LINE 30 "J6>i,14- FOUNDATION AGRICULTURE WELL THER WELL 7/Op� PITS/SUMPS '2 001 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation -17 Dia. of Well Casing r " XDomest 0 Gravel Pack// ❑ Tracy Type of Casing—JavG Specifications i'1 Public Other(lQab_-Ar_ n Delta Depth of Grout Seal Type of Grout I I Irrigation !�O_Approx. Depth I 1 Eastern Surface Seal Installed by -a; � Repair Work Done U Type of Pump N11 H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material A Depth Ca—le.,7`�/6C Depth 30 t Filler Material & Depth �J�cs?!L Sa 5" TYPE OF SEPTIC 4,�f�ORK: NEW INSTALLATION I i REPAIR/ADDITION 1 i DESTRUCTION 1 I INo septic system permitted if public wwer is ��/� available within 200 feet.) (� Installation will serve: Residence— Commercial_ Other �1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth t 5 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINEV/�, ❑ No. b Length of lines Total length/size FILTER BED v ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Ne I 1 Depth Sire Number SUMPS , ` Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 4 rules and regulations of the San Joaquin County1 Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall not C employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing o averse side. Signed Title: FOR DEPARTMENT USE ONLY �j Application Accepted by q ye Date �" o ` v Area ` Pit or Grout Inspection Date ' o- Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE CK INFO AMOUNT DUE AMOU-N-T REMITTED CASH I RECEIVEp BY !DATE PERMIT NO. . EH13•24 ISEv.rsi EH 71•26 ,�.